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Distal Tibial Plafond Fractures


Introduction


High energy intraarticular fractures of the distal tibia (tibial plafond fractures, or pilon fractures) present a great challenge to the orthopaedic surgeon. These injuries often result in a significant soft tissue damage, comminution of bone, and disruption of the articular cartilage and subchondral bone. The treatment strategy used in dealing with tibial plafond fractures is strongly influenced by the often-precarious soft tissue conditions. These conditions result both from the high-energy of the injury and the relatively non-compliant and poorly vascularized soft tissues surrounding the distal tibia and ankle. The high-energy injury may traumatize the skin and the subcutaneous tissues, resulting in massive swelling that may lead to the early formation of post-traumatic bullae. Skin necrosis may also ensue if the soft tissues are further traumatized by ill-advised or poorly timed surgical procedures.

Due to the great treatment challenges posed by this high-energy injury, there has been much controversy about the most appropriate and best treatment for tibial plafond fractures. Factors such as timing of treatment, method of stabilization, techniques of operative care, and postoperative rehabilitation have all been hotly debated and, at times, contested by various orthopaedists. This chapter will attempt to comprehensively address the anatomy, physiology, and diagnosis of this injury; it will also discuss various treatment modalities, and the importance of tailoring treatment to the extent of the bony and soft tissue injuries.

Controversy has surrounded even the proper terminology with which to describe high-energy articular fractures of the distal tibia. In French speaking countries, the distal end of the tibia is called “pilon”. Pilon means pestle or rammer, and the verb pilonner means to ram or to stamp. Therefore a fracture of the tibial pilon always implies axial loading (ramming) causing damage to the weight bearing articular surface of the distal tibia (pestle). In German speaking countries, these fractures were initially described as stauchung (compression), a term reflecting the mechanism of the injury. The word eclatement (explosion) was also used by the French to describe the mechanism of this particular injury. It is believed by many that the French term, pilon tibial is most applicable and concise in an attempt to characterize both the injury, and the mechanism of the injury. It is for this reason that the term pilon fracture has become widely employed in referring to these fractures.

The distal articular surface of the tibia has a quadrangular shape with an arch in the sagittal plane. This surface has been called a plafond, a French word originating from plat, meaning “flat”, and fond, meaning “bottom”. In English, plafond refers to an elaborate ceiling. Hence, fractures of the distal tibial articular surfaces have also been referred to as tibial plafond fractures. One additional term for this fracture has been pylon; this originated probably as a misspelling of the French pilon, but the French word pylone means a bridge or a stone archway. Particularly this latter definition of the word pylone has probably helped perpetuate the use of the term pylon in occasionally describing these injuries.